Provider Demographics
NPI:1295269108
Name:PENA, MARIA LUISA (CADC II A012600315)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LUISA
Last Name:PENA
Suffix:
Gender:F
Credentials:CADC II A012600315
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 GARNET ST APT 8
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-3362
Mailing Address - Country:US
Mailing Address - Phone:310-849-6997
Mailing Address - Fax:
Practice Address - Street 1:13931 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2941
Practice Address - Country:US
Practice Address - Phone:310-768-8018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACADC11A012600315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)